Contents lists available at ScienceDirect Transfusion and Apheresis Science journal homepage: www.elsevier.com/locate/transci Factors that contribute to blood donation behavior among primary healthcare users: A structural approach Miriane L. Zucoloto a, ⁎ , Thelma T. Gonçalez b , Philippe T. Gilchrist c , Brian Custer b,d , Willi McFarland d , Edson Z. Martinez a a Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil b Vitalant Research Institute, San Francisco, CA, United States c Macquire University, New South Wales, Australia d University of California San Francisco, San Francisco, CA, United States ARTICLE INFO Keywords: Blood donation Knowledge Fear Religiosity Community health Primary healthcare ABSTRACT This study aimed to evaluate the relative contribution of psychosocial variables to donation behavior in a sample of primary healthcare users in a Brazilian municipality. Donor recruitment and retention continue to pose sig- nificant challenges to blood collection services worldwide and is especially important among low and middle income countries (LMICs), challenged with higher rates of stigma and low public awareness about donation. A cross-sectional study with randomized stratified sampling of 1055 primary healthcare users was conducted across 12 healthcare facilities in Ribeirão Preto, state of São Paulo. Participants completed measures assessing psychosocial variables, including religiosity, knowledge regarding blood donation process, overall quality of life, blood donation of peers, sociodemographic variables, and the fear of blood, injections, and fainting. The asso- ciations between psychosocial variables and donation behaviour was examined using structural equation modelling. Blood donation was more frequent in males and among individuals with higher socioeconomic and educational levels. The structural model indicated associations between blood donation behaviour and fear, knowledge, age, sex, socioeconomic status, and educational level. Fear of blood, injections and vasovagal re- actions, and a lack of knowledge of the donation process were revealed as important barriers to the decision to donate blood. In addition, there is evidence that considering the population of primary healthcare users, the women, the youngers, and those with lower socioeconomic status and lower educational level are less likely to donate blood. 1. Introduction Recruitment and retention of voluntary blood donors is a con- siderable challenge in the face of high blood demand and low blood donation rates, especially in low and middle income countries (LMICs) [1,2]. Stigma and the overall low public awareness of the blood do- nation procedures and standards have compromised the quantity and safety of the blood supply in LMICs [3]. In Brazil, the number of blood donors is below expected levels. According to recent data from the Brazilian Ministry of Health, blood donor rates have stabilized around 1.9% in the last five years [1,4]. In addition, similar to other LMICs, the majority of first-time donors do not return and only 40% of Brazilians blood donors are classified as repeat donors, i.e. those who make at least two donations per year [1]. Psychosocial variables are integral in contemporary models predicting donation intention and behavior [5,6]. Knowledge regarding blood donation process, religious beliefs and altruistic feelings, well- being and quality of life, as well as positive perception of health, have been pointed to as relevant motivating factors [7–15]. An emerging body of research has also emphasized different aspects of fear as im- portant barriers to donation behavior and donor return in recent do- nors, first-time donors, students, females, young adults and individuals with different levels of donation experience [16–19]. Psychosocial and behavioral contributors to donation behavior differ between sub-populations and are not static elements that need to be routinely investigated [20,21]. In addition, the investigation of non- donors population is scarce and necessary in order to continue to attract new donor populations. Although some studies have already flagged some barriers to blood donation among the general public, there is conflicting evidence about the strength and direction of these https://doi.org/10.1016/j.transci.2019.08.020 Received 29 May 2019; Received in revised form 30 July 2019; Accepted 2 August 2019 ⁎ Corresponding author. E-mail address: mirianezucoloto@usp.br (M.L. Zucoloto). Transfusion and Apheresis Science xxx (xxxx) xxx–xxx 1473-0502/ © 2019 Elsevier Ltd. All rights reserved. Please cite this article as: Miriane L. Zucoloto, et al., Transfusion and Apheresis Science, https://doi.org/10.1016/j.transci.2019.08.020